Spritam

Generic: levetiracetam

250 MG — Tablet

Second Generation — Patients with a diagnosis of seizure disorder are exempt from T/F criteria and may use any second generation product.

Also known as: levetiracetam
GoodRx Compare Prices

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Gold
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Silver
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze
via Roweepra 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via Roweepra 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via Roweepra 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Silver
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Gold
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Complete Gold
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via Roweepra 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Complete Gold
via levetiracetam 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Roweepra 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via Roweepra 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Roweepra 		Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via levetiracetam 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via levetiracetam 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via levetiracetam 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Keppra Xr 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Keppra 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Elepsia XR 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Elepsia XR 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Keppra 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Keppra Xr 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: May 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026
via Keppra 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Keppra 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Keppra 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Keppra 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Keppra 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Keppra Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Keppra Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Keppra Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Keppra Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Keppra Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026
via levetiracetam 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Roweepra 		Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: May 13, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 180 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 180 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 180 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 180 per 30 days PA | QL
Troy Medicare (HMO)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Senior Care (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Roweepra 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via levetiracetam 		Tier 1 - Preferred Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Roweepra 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring Preferred (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
HealthSpring Preferred (HMO)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via Roweepra 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — ✓ 120 per 30 days QL
Wellcare Simple Open (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via levetiracetam 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Blue Medicare Choice (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Blue Medicare Essential (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health Platinum (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via levetiracetam 		Tier 2 - Generic — — — None
Alignment Health Platinum (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Assist Open (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via Roweepra 		Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Roweepra 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via levetiracetam 		Tier 2 - Generic — — ✓ 120 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO) Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5216-211 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Full Access H5525-034 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-049 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-050 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-070 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-083 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via levetiracetam 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Troy Medicare (HMO) Tier 4 - Non-Preferred — ✓ ✓ 60 per 30 days ST | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 60 per 30 days ST | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 180 per 30 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via levetiracetam 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via levetiracetam 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Wellcare Dual Access (HMO-POS D-SNP)
via levetiracetam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via levetiracetam 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 180 per 30 days ST | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via levetiracetam 		Tier 4 - Non-Preferred — — — None
Senior Care (HMO I-SNP) Tier 4 - Non-Preferred ✓ — ✓ 180 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Roweepra 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Elepsia XR 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via levetiracetam 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Roweepra 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via levetiracetam 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via levetiracetam 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via levetiracetam 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Roweepra 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Roweepra 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Keppra 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Keppra 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Keppra 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: May 29, 2026  ·  Checked: 17 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via levetiracetam 		Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Roweepra 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via levetiracetam 		Tier 2 - Lower Cost — — — None
Something not right?